Lupine Publishers | Journal of Pediatric Dentistry
Abstract
Dens invaginates is a defect categorized by a prominent lingual
cusp and centrally located fossa. It occurs due to early
invagination of the enamel epithelium into dental papilla of the
underlying tooth germ. The affected teeth show a deep invagination
of enamel as well as dentin initiating from foramen caecum or tip
of the cusps and may extend even into the root. The teeth that
are most frequently involved teeth are the maxillary lateral
incisors, there might also occur a bilateral involvement. In this
anomaly
there can be seen several morphologic variations and it may lead to
early pulpal involvement from the caries progressing into the
pulp from lingual pit. The treatment varies from a preventive
restoration to endodontic therapy, depending on the severity of the
case. The present case report refers to one such case having a deep
lingual pit bilaterally in both the maxillary permanent lateral
incisors.
Introduction
Dens invaginatus is a rare malformation of teeth, showing
various morphological variations. Radiographically the teeth show
an invagination of enamel and dentin extending up to the pulp
cavity or the roots. This malformation was described earliest by
Ploquet [1], who discovered this anomaly in a whale’s tooth [2].
Dens invaginatus in a human tooth was first described by a dentist
Socrates’ in 1856 [3]. ‘Anomalous cavities in human teeth were
reported by Mühlreiter [4] in 1873, Baume [5] in 1874 and Busch
[6] in 1897 reported about this anomaly as well. In 1887 Tomes
[7] described the dens invaginatus as: The enamel of the coronal
portion is generally well developed but we tend to find a small
depression in its centre that appears to be a dark spot. On division
of the tooth longitudinally, there occurs a dark centre of depression
that is a blocked orifice within the tooth. If the section be a fortunate
one, we shall be able to trace the enamel as it is continued from the
exterior of the tooth through the opening into the cavity, the surface
of which is lined completely with this tissue’ [7]. There are various
reports on cases of dens invaginatus malformation in the dental
literature [8-11]. Synonyms for this anomaly include:
a) Dens in dente,
b) Invaginated odontome,
c) Dilated gestant odontome,
d) Dilated composite odontome,
e) Tooth inclusion,
f) Dentoid in0 dente.
Case Report
A 12-year-old female patient referred to the Pedodontics
department with the complaint of irregularly arranged teeth.
General health of the patient was normal and medical history was
not relevant. Clinical examination revealed teeth 12 and 22 with
a lingual pit. The pre-operative photographs were taken for the
same (Figure 1). An intraoral Periapical radiograph was also taken
for both the teeth, which revealed deep lingual pits involving the
coronal part of teeth (Figure 2). As the teeth showed only incisal
invaginations, and no pulpal involvement preventive treatment
was selected. Also, if the pits were left untreated, it would harbor
irritants and microorganisms further leading to caries. And as these
pits were deep enough, the caries would progress rapidly into the
pulp and cause pulpal infection leading to the need for endodontic
treatments.
Figure 1: Pre-operative photograph.
Figure 2a: IOPA.
Figure 2b: IOPA.
Treatment Done
Following the oral prophylaxis, rubber dam placement was
done for 12 and 22 (Figure 3). The teeth were initially washed,
cleaned and dried. After that acid etching was performed using
37% phosphoric acid for 20 seconds. It was then washed and
dried. Following that dentin bonding agent was applied with the
applicator tip and cured for 20 seconds. The pits were then
restored
with flowable composite bilaterally (Figure 4). The teeth were
then examined for any excess material and later finishing was done.
The occlusion was also checked for any interference followed by
post-operative photographs (Figure 5). Furthermore, the child was
referred for orthodontic consultation.
Figure 3: IOPA.
Figure 3: Rubberdam placement.
Figure 4: Composite restoration.
Figure 5: Post-operative view.
Discussion
Dens Invaginatus has several variations of it. Oehlers gave a
classification for various types of dens invaginatus [12]:
a) Type I: an enamel-lined minor form occurring within the
confines of the crown not extending beyond the amelocemental
junction.
b) Type II: an enamel-lined form which invades the root but
remains confined as a blind sac. It may or may not communicate
with the dental pulp.
c) Type III: a form which penetrates through the root
perforating at the apical area showing a ‘second foramen’ in
the apical or in the periodontal area. There is no immediate
communication with the pulp. The invagination may be
completely lined by enamel, but frequently cementum will be
found lining the invagination.
Prevalence of Dens Invaginatus
The teeth mainly affected are maxillary lateral incisors and
bilateral occurrence is not rare, they occur in almost 43% of all cases
[13]. Swanson & McCarthy (1947) were the foremost to present
bilateral dens invaginatus malformation, Conklin (1968) presented
a patient with both maxillary central and lateral incisors affected
bilaterally, and Burton et al. (1980) reported a case with six teeth
involved, the maxillary incisors as well as the maxillary canines.
Krolls (1969) also detected dental invaginations in maxillary
central incisors and in many maxillary and mandibular premolars
in a single patient. Conklin (1978) found the malformation in
four mandibular incisors in one patient. There are many theories
described in the literature to explain about the dental coronal
invaginations some of them being:
a) The bulking of the enamel organ was thought to be caused
due to the growth pressure of the arches [14,15].
b) Focal failure of the growth of the inner enamel epithelium
leads to the invaginations; however, the surrounding epithelium
continues to grow and engulfs the static area [11].
c) The invagination is due to the aggressive proliferation of a
part of the inner enamel epithelium invading the dental papilla.
It was thought as a ‘benign neoplasm of limited growth [16].
d) Protrusion and distortion of the enamel organ is thought
to cause an enamel lined channel terminating at the cingulum
or at the incisal tip. This might also lead to an irregular crown
formation [17,18].
e) The ‘twin-theory’ [18] suggested a fusion of two toothgerms to be the causative factor.
f) Infection was also considered to be responsible for the
anomaly [19].
g) Trauma was thought to be a reason, but they could not
adequately explain why just maxillary lateral incisors were
affected and not central incisors [20].
h) Most authors consider dens invaginatus as a deep folding
of the foramen coecum during tooth development which may
even result in a second apical foramen [3].
i) On the other hand, the invagination also may start from
the incisal edge of the tooth. Genetic factors cannot be expelled
(Grahnen 1962, Casamassimo et al. 1978, Ireland et al. 1987,
Hosey & Bedi 1996).
Clinical Features
Due to the invagination there is just a thin layer of enamel and
dentin left, which thus allows several microbes into the pulpal
space easily. In some of the cases there is a complete enamel lining
present. Also, channels may be present between the invagination
and the pulp chamber. Pulp necrosis hence occurs in the earlier
stages, within a few years of eruption and may be even before the
root closure. The sequelae of untreated coronal invaginations can
be as follows:
a) Abscess formation.
b) Retention of neighboring teeth.
c) Displacement of teeth.
d) Cysts, or Internal resorption.
Treatment Modalities
Preventive and restorative treatment should be opted for teeth
with deep palatal or incisal invaginations and should be treated by
fissure sealing [21]. Also, composite resin restoration followed by
pit and fissure sealant can be done in the required cases [21]. Root
canal treatment, surgical treatment and extraction of teeth should
be done in severe cases wherein there is radicular invagination and
pulpal involvement.
Conclusion
The clinician should be aware of occurrence of such tooth
anomalies and should do a thorough clinical diagnosis as these
anomalies are not rare. Earlier diagnosis and treatment of such
cases can prevent further complications such as endodontic
therapies and extractions. Hence the needed treatment should
be done as early as possible and a periodic follow up should be
maintained.
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